Early postoperative ERAS compliance predicts decreased length of stay and complications following liver resection

Related factors associated with the prognosis of children undergoing liver transplantation under the enhanced recovery after surgery nursing concept

This study aimed to investigate factors associated with the clinical outcomes of patients who underwent pediatric liver transplantation (LT) and received enhanced recovery after surgery (ERAS) nursing. A cohort of 104 pediatric patients was studied at our hospital. Data on 8 indicators and 2 clinical outcomes, including length of hospital stay (LOS) and 30-day readmission rates, were collected. Linear and logistic regression analyses were employed to examine the associations of the 8 indicators with hospital-LOS and readmission risks, respectively. The predictive value of these indicators for the outcomes was determined using the receiver operating characteristic (ROC) curve, decision curve analysis, and importance ranking through the XGBoost method. A comprehensive model was developed to evaluate its predictive accuracy. Regression analyses identified donor age, donor gender, and intensive care unit (ICU)-LOS of recipients as significant predictors of hospital LOS (all P < .05), whereas no indicators were significantly associated with readmission risk. Further, ROC analysis revealed that 3 indicators provided superior prediction for 28-day hospital LOS compared to the median LOS of 18 days. ICU-LOS demonstrated the highest clinical net benefit for predicting 28-day hospital-LOS. Multivariable regression analysis confirmed the independent predictive value of donor age and ICU-LOS for the hospital-LOS (all β > 0, all P < .05). Although the comprehensive model incorporating donor age and ICU-LOS showed stable predictive capability for hospital-LOS, its performance did not significantly exceed that of the individual indicators. In pediatric LT, hospital LOS warrants greater emphasis over readmission rates. Donor age and ICU-LOS emerged as independent risk factors associated with prolonged hospital LOS.

Does enhanced recovery after surgery programs improve clinical outcomes in liver cancer surgery?

Enhanced recovery after surgery (ERAS) programs have been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016 and the new recommendations in 2022. Liver surgery is usually performed in oncological patients (liver metastasis, hepatocellular carcinoma, cholangiocarcinoma, etc.), but the real impact of liver surgery ERAS programs in oncological outcomes is not clearly defined. Theoretical advantages of ERAS programs are: ERAS decreases postoperative complication rates and has been demonstrated a clear relationship between complications and oncological outcomes; a better and faster postoperative recovery should let oncologic teams begin chemotherapeutic regimens on time; prehabilitation and nutrition actions before surgery should also improve the performance status of the patients receiving chemotherapy. So, ERAS could be another way to improve our oncological results. We will discuss the literature about liver surgery ERAS focusing on its oncological implications and future investigations projects.

Robotic approach together with an enhanced recovery programme improve the perioperative outcomes for complex hepatectomy

Objective

Robotic surgery has more advantages than traditional surgical approaches to complex liver resection; however, the robotic approach is invariably associated with increased cost. Enhanced recovery after surgery (ERAS) protocols are beneficial in conventional surgeries.

Methods

The present study investigated the effects of robotic surgery combined with an ERAS protocol on perioperative outcomes and hospitalization costs of patients undergoing complex hepatectomy. Clinical data from consecutive robotic and open liver resections (RLR and OLR, respectively) performed in our unit in the pre-ERAS (January 2019-June 2020) and ERAS (July 2020-December 2021) periods were collected. Multivariate logistic regression analysis was performed to determine the impact of ERAS and surgical approaches-alone or in combination-on LOS and costs.

Results

A total of 171 consecutive complex liver resections were analyzed. ERAS patients had a shorter median LOS and decreased total hospitalization cost, without a significant difference in the complication rate compared with the pre-ERAS cohort. RLR patients had a shorter median LOS and decreased major complications, but with increased total hospitalization cost, compared with OLR patients. Comparing the four combinations of perioperative management and surgical approaches, ERAS + RLR had the shortest LOS and the fewest major complications, whereas pre-ERAS + RLR had the highest hospitalization costs. Multivariate analysis found that the robotic approach was protective against prolonged LOS, whereas the ERAS pathway was protective against high costs.

Conclusions

The ERAS + RLR approach optimized postoperative complex liver resection outcomes and hospitalization costs compared with other combinations. The robotic approach combined with ERAS synergistically optimized outcome and overall cost compared with other strategies, and may be the best combination for optimizing perioperative outcomes for complex RLR.

Compliance with enhanced recovery after surgery predicts long-term outcome after hepatectomy for cholangiocarcinoma

BACKGROUND

Enhanced recovery after surgery (ERAS) program has been proved to improve postoperative outcome for many surgical procedures, including liver resection. There was limited evidence regarding the feasibility and benefit of ERAS in patients who underwent liver resection for cholangiocarcinoma.

AIM

To evaluate the feasibility of ERAS in patients who underwent liver resection for cholangiocarcinoma and its association with patient outcomes.

METHODS

We retrospectively analyzed 116 cholangiocarcinoma patients who underwent hepatectomy at Srinagarind Hospital, Khon Kaen University between January 2015 and December 2016. The primary outcome was the compliance with ERAS. To determine the association between ERAS compliance and patient outcomes. the patients were categorized into those adhering more than and equal to 50% (ERAS ≥ 50), and below 50% (ERAS < 50) of all components. Details on type of surgical procedure, preoperative and postoperative care, tumor location, postoperative laboratory results, and survival time were evaluated. The compliance with ERAS was measured by the percentage of ERAS items achieved. The Kaplan-Meier curve was used for survival analysis.

RESULTS

The median percentage of ERAS goals achieved was 40% (± 12%). Fourteen patients (12.1%) were categorized into the ERAS ≥ 50 group, and 102 patients were in the ERAS < 50 group. Postoperative hospital stay was significantly shorter in the ERAS ≥ 50 group [8.9 d, 95% confidence interval (CI): 7.3-10.4 d] than in the ERAS < 50 group (13.7 d, 95%CI: 12.2-15.2 d) (P = 0.0217). No hepatobiliary-related complications or in-hospital mortality occurred in the ERAS ≥ 50 group. Overall survival was significantly higher in the ERAS ≥ 50 group. The median survival of the patients in the ERAS < 50 group was 1257 d (95%CI: 853.2-1660.8 d), whereas that of the patients in the ERAS ≥ 50 group was not reached.

CONCLUSION

Overall ERAS compliance for patients who underwent liver resection for cholangiocarcinoma is poor. Greater ERAS compliance could predict in-hospital, short-term, and long-term outcomes of the patients.

Abdominal drainage is contraindicated after uncomplicated hepatectomy: Results of a meta-analysis of randomized controlled trials

BACKGROUND

No conclusive recommendations exist regarding use of abdominal drainage in hepatectomy. The practice of abdominal drainage remains commonplace despite unfavorable outcomes reported by randomized controlled trials. We aimed to compare the impact of abdominal drainage on outcomes of hepatectomy.

METHODS

A systematic search of electronic information sources and bibliographic reference lists was conducted. A combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits in each of the above databases was applied. Overall perioperative and wound-related complications, bile leak, intra-abdominal collections (including those requiring an intervention), and the length of hospital stay were the evaluated outcome parameters.

RESULTS

Seven randomized controlled trials reporting 1,064 patients undergoing hepatectomy with (n = 533) or without (n = 531) placement of abdominal drain were included. Patients in both groups were of comparable age (P = .23), sex (P = .49), proportion of major hepatectomy (P = .93), minor hepatectomy (P = .96), cirrhosis (P = .78), and malignant pathologies (P = .61). Drainage after hepatectomy was associated with significantly higher overall complications (RR: 1.37, P = .0003) and wound-related complications (risk ratio: 2.29, P = .01) compared to no drainage. Moreover, there was no significant difference in bile leak (risk ratio: 2.15, P = .19), intra-abdominal collections (risk ratio: 1.13, P = .70), intra-abdominal collections requiring interventions (risk ratio: 1.19, P = .71), or length of hospital stay (mean difference: 0.37, P = .67) between the 2 groups. The trial sequential analysis confirmed conclusiveness of the findings.

CONCLUSION

Abdominal drainage after hepatectomy increases overall and wound-related complications, without any reduction in the risk of intra-abdominal collections needing an intervention. Routine drainage after an uncomplicated hepatectomy should be avoided, with the possible exception of the presence of a bilioenteric anastomosis.